By Counterforce Health Team in Cosentyx (secukinumab) —

How to Get Cosentyx (secukinumab) Covered by UnitedHealthcare in Pennsylvania: Complete PA Guide with Appeals Process

Answer Box: Getting Cosentyx Covered by UnitedHealthcare in Pennsylvania

UnitedHealthcare requires prior authorization for Cosentyx (secukinumab) with step therapy through preferred biologics first. Submit PA via the UHCprovider.com portal with diagnosis documentation, prior treatment failures, and clinical response data. If denied, Pennsylvania's new external review program overturns ~50% of denials. Start today: Log into the UHC provider portal, download the current Cosentyx PA form, and gather documentation of failed conventional therapies and any prior biologics.

Table of Contents

  1. Start Here: Verify Your Plan and Find Current Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Upload Instructions
  4. Step-by-Step: Fastest Path to Approval
  5. Common Denial Reasons and How to Fix Them
  6. Appeals Process in Pennsylvania
  7. Specialty Pharmacy Enrollment
  8. Support Lines and Contact Information
  9. Pennsylvania External Review Program
  10. FAQ

Start Here: Verify Your Plan and Find Current Forms

Before starting your Cosentyx prior authorization, confirm these basics:

1. Check Your Plan Type

  • Look at your UnitedHealthcare ID card for your specific product (Commercial, Medicare Advantage, Community Plan)
  • Verify if OptumRx manages your pharmacy benefits (common for most UHC plans)
  • Important: Self-funded employer plans have different rules than fully-insured commercial plans

2. Confirm Cosentyx Coverage Download your current UnitedHealthcare Prescription Drug List to verify:

  • Cosentyx is listed on your formulary
  • Tier placement (typically specialty tier)
  • Any "PA" (prior authorization) or "ST" (step therapy) notations

3. Get the Current PA Policy UnitedHealthcare's 2025 Cosentyx policy (Program Number 2024 P 2196-15) is available through the UHC provider portal. This policy applies to commercial plans unless superseded by state mandates or member-specific benefit design.

Prior Authorization Forms and Requirements

Current Forms (Updated 2024-2025)

Primary Form: UnitedHealthcare Cosentyx Prior Authorization/Medical Necessity Form

Alternative: Cosentyx Notification Form (2025 version with similar criteria)

Note: OptumRx marks their forms "DO NOT COPY FOR FUTURE USE" because they're updated frequently. Always download the current version.

Required Documentation

For All Indications:

  • Documented diagnosis with ICD-10 code
  • Age verification consistent with FDA labeling
  • Planned dosing regimen per FDA label
  • Attestation of no concurrent targeted immunomodulator use

Condition-Specific Requirements:

Indication Key Documentation Prior Therapy Requirements
Moderate-severe plaque psoriasis BSA involvement, PASI score, functional impact High-potency topical + systemic therapy (MTX, cyclosporine, acitretin, or phototherapy) + often 1 preferred biologic
Psoriatic arthritis Active disease signs, joint counts, enthesitis Conventional DMARDs unless contraindicated
Ankylosing spondylitis Objective inflammation markers, imaging NSAIDs, conventional therapy
Hidradenitis suppurativa Hurley stage II-III documentation Antibiotics, other conventional treatments

Submission Portals and Upload Instructions

UnitedHealthcare Provider Portal

Access: UHCprovider.com

  • Register with One Healthcare ID if new user
  • Navigate to "Prior Authorization and Notification" tab
  • Use Document Library tool to upload supporting files

Upload Requirements:

  • Clinical notes with diagnosis and severity assessment
  • Prior therapy documentation with dates, doses, outcomes
  • Lab results or imaging if relevant to diagnosis
  • Prescriber specialty verification

Alternative Submission Methods

Fax: Use the fax number listed on the current PA form (verify with latest version) Phone: 877-842-3210 (Medicare Advantage) or 888-397-8129 (select plans)

Tip: Electronic submission through the portal is fastest and allows real-time status tracking via the TrackIt tool.

Step-by-Step: Fastest Path to Approval

Step 1: Gather Required Documentation (Patient/Clinic)

  • Insurance card and member ID
  • Complete medication history with dates and outcomes
  • Recent clinic notes showing current disease severity
  • Lab results supporting diagnosis

Step 2: Complete Prior Authorization Form (Prescriber)

  • Download current UHC Cosentyx PA form
  • Fill all sections completely, especially prior therapy details
  • Include specific reasons for treatment failures or contraindications

Step 3: Submit via Provider Portal (Clinic Staff)

  • Log into UHCprovider.com
  • Use Prior Authorization tool
  • Upload all supporting documents
  • Timeline: Standard review takes up to 72 hours for urgent cases, longer for routine

Step 4: Track Status and Respond to Requests

  • Use TrackIt tool in provider portal
  • Respond promptly to any requests for additional information
  • Consider peer-to-peer review if initial review is unfavorable

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Required Documentation
Step therapy not completed Document failed trials of preferred biologics Detailed medication history with specific failure reasons
Insufficient severity documentation Provide objective disease measures PASI scores, BSA measurements, joint counts, Hurley staging
Missing prior therapy trials Document conventional treatment attempts Dates, doses, duration, specific outcomes or side effects
Concurrent biologic use Confirm Cosentyx monotherapy Medication reconciliation, prescriber attestation
Age restrictions Verify FDA labeling compliance Birth date, indication-specific age requirements

Appeals Process in Pennsylvania

Internal Appeals (Required First Step)

First-Level Appeal:

  • Submit within 180 days of denial
  • Use UHC appeals form or written request
  • Address each denial reason point-by-point
  • Include additional clinical evidence

Peer-to-Peer Review:

  • Available during PA or appeal process
  • Request through UHC provider services
  • Direct physician-to-physician discussion

Pennsylvania External Review Program

Pennsylvania launched a state-run external review program in January 2024 with impressive results:

Success Rate: Approximately 50% of denials are overturned Eligibility: Fully-insured commercial plans (not self-funded employer plans) Timeline: 4 months from final internal denial to request external review

How to Request External Review:

  1. Complete UHC's internal appeals process
  2. Receive "Final Adverse Benefit Determination" letter
  3. Submit request via Pennsylvania Insurance Department portal
  4. Upload supporting medical documentation

Contact for Help: Pennsylvania Insurance Department Consumer Services at 1-877-881-6388

Specialty Pharmacy Enrollment

UnitedHealthcare typically requires Cosentyx to be dispensed through a contracted specialty pharmacy, often OptumRx/Optum Specialty Pharmacy.

New Enrollment Process

  1. After PA Approval: UHC or OptumRx will contact you about specialty pharmacy enrollment
  2. Benefits Verification: Specialty pharmacy will verify coverage and copay assistance options
  3. Delivery Setup: Arrange temperature-controlled shipping and injection training if needed

Transferring Existing Prescription

  1. Call UHC Member Services (number on ID card) to initiate transfer
  2. Authorize Release: Allow current specialty pharmacy to transfer prescription and records
  3. Transition of Care: Request temporary coverage during transfer if doses are due soon
From our advocates: "We've seen patients successfully transfer Cosentyx prescriptions by calling UHC proactively and requesting expedited transfer. Having your next injection date ready helps them prioritize continuity of care."

Support Lines and Contact Information

UnitedHealthcare Contact Numbers

  • Member Services: Number on your ID card
  • Provider Services: 877-842-3210 (Medicare Advantage)
  • Prior Authorization Status: Available through provider portal or phone

Pennsylvania-Specific Resources

  • PA Insurance Department Consumer Services: 1-877-881-6388
  • External Review Questions: Use same number or online portal
  • Pennie Marketplace Support: If purchased through state marketplace

What to Ask When Calling

  • "Is prior authorization required for Cosentyx on my plan?"
  • "What step therapy requirements apply?"
  • "Which specialty pharmacy must I use?"
  • "What's my copay or coinsurance for Cosentyx?"

Pennsylvania External Review Program

Pennsylvania's Independent External Review Program, launched in January 2024, has proven to be a powerful tool for overturning insurance denials.

Key Statistics

  • 517 appeals filed in the first year
  • 259 denials overturned (50.1% success rate)
  • Standard timeline: Decision within 45 days
  • Expedited timeline: Decision within 72 hours for urgent cases

When to Use External Review

  • After completing UHC's internal appeals process
  • When you have strong medical evidence supporting necessity
  • For denials based on "not medically necessary" or step therapy requirements
  • When treatment delay could seriously impact your health

The external review decision is binding on UnitedHealthcare. If approved, they must cover Cosentyx and may owe retroactive reimbursement for out-of-pocket costs.

How Counterforce Health Can Help

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform identifies the specific denial basis—whether it's prior authorization criteria, step therapy requirements, or "not medically necessary" determinations—and drafts point-by-point responses aligned to UnitedHealthcare's own rules.

For Cosentyx appeals, Counterforce Health can help gather the right evidence citations from FDA labeling, peer-reviewed studies, and specialty guidelines, weaving them into appeals that meet Pennsylvania's procedural requirements while tracking deadlines and required documentation.

FAQ

How long does UnitedHealthcare prior authorization take for Cosentyx in Pennsylvania? Standard PA reviews take 5-14 business days. Urgent cases can be expedited to 24-72 hours with appropriate clinical justification.

What if Cosentyx is non-formulary on my UHC plan? You can request a formulary exception with strong medical necessity documentation. Alternative coverage may be available through medical benefit for certain indications.

Can I request an expedited appeal in Pennsylvania? Yes, both UHC internal appeals and Pennsylvania external reviews offer expedited processes when treatment delay poses serious health risks.

Does step therapy apply if I've already failed biologics outside Pennsylvania? Yes, document all prior biologic trials regardless of where they occurred. UHC recognizes treatment history from other states and plans.

What happens if my UHC plan is self-funded? Self-funded employer plans are not eligible for Pennsylvania's external review program. You may have federal ERISA appeal options instead.

How much does Cosentyx cost with UnitedHealthcare coverage? Costs vary by plan design. Specialty tier copays typically range from $50-200+ per month. Novartis offers copay assistance programs that may reduce out-of-pocket costs.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance. For assistance with complex appeals, consider contacting the Pennsylvania Insurance Department Consumer Services or consulting with healthcare coverage specialists.

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